WellCare Advocate Complete FIDA(Medicare - Medicaid Plan) : Home

236 Pages·2015·2.3 MB·English

H2751_NY030500_MMP_MHB_ENG CMS Approved 09242015
WELLCARE ADVOCATE COMPLETE FIDA
(MEDICARE-MEDICAID PLAN)
PARTICIPANT HANDBOOK
©WellCare 2015 NY_06_15 NY6MPPMHB67985E_0615

H2751_NY030500_MMP_MHB_ENG
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
Participant Handbook
January 01, 2016 – December 31, 2016

Your Health and Drug Coverage under WellCare Advocate Complete
FIDA
This handbook tells you about your coverage under WellCare Advocate Complete FIDA
(Medicare-Medicaid Plan) from the date you are enrolled with WellCare Advocate
Complete FIDA through December 31, 2016. It explains how WellCare Advocate
Complete FIDA covers Medicare and Medicaid services, including prescription drug
coverage, at no cost to you. It explains the health care services, behavioral health
services, prescription drugs, and long-term services and supports that WellCare
Advocate Complete FIDA covers. Long-term services and supports include long-term
facility-based care and long-term community-based services and supports. Long-term
community-based services and supports provide the care you need at home and in your
community, and can help reduce your chances of going to a nursing facility or hospital.
This is an important legal document. Please keep it in a safe place.
WellCare Advocate Complete FIDA is a Fully Integrated Duals Advantage (FIDA) Plan
that is offered by WellCare Health Plan, Inc. When this Participant Handbook says “we,”
“us,” or “our,” it means WellCare Health Plan, Inc. When it says “the plan” or “our plan,”
it means WellCare Advocate Complete FIDA.
Disclaimers
WellCare is a managed care plan that contracts with both Medicare and the New York
State Department of Health (Medicaid) to provide benefits of both programs to
Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.
Limitations and restrictions may apply. For more information, call WellCare Advocate
Complete FIDA Participant Services or read the WellCare Advocate Complete FIDA
Participant Handbook. This means that you need to follow certain rules to have
WellCare Advocate Complete FIDA pay for your services.
The List of Covered Drugs and/or pharmacy and provider networks may change
throughout the year. We will send you a notice before we make a change that affects
you.
Benefits may change on January 1 of each year.
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-
2063 (TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call
?
is free. For more information, visit https://fida.wellcareny.com/. 1
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK

You can get this information for free in other formats, such as large print, braille, or
audio. Call 1-855-595-2063 and TTY/TDD 1-877-247-6272 during 8 a.m. to 8 p.m.
Eastern, Monday – Sunday. The call is free.
The State of New York has created a Participant Ombudsman Program called the
Independent Consumer Advocacy Network (ICAN) to provide Participants free,
confidential assistance on any services offered by WellCare Advocate Complete FIDA.
ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-
2063 (TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call
?
is free. For more information, visit https://fida.wellcareny.com/. 2
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK
Chapter 1: Getting started as a Participant
Table of Contents
A. Welcome to WellCare Advocate Complete FIDA ............................................................... 4
B. What are Medicare and Medicaid? .................................................................................... 4
Medicare ............................................................................................................................ 4
Medicaid............................................................................................................................. 4
C. What are the advantages of this FIDA Plan? ..................................................................... 5
D. What is WellCare Advocate Complete FIDA’s service area? ............................................. 6
E. What makes you eligible to be a plan Participant? ............................................................. 6
F. What to expect when you first join a FIDA plan.................................................................. 7
G. What is a Person-Centered Service Plan? ......................................................................... 7
H. Does WellCare Advocate Complete FIDA have a monthly plan premium? ........................ 8
I. About the Participant Handbook ........................................................................................ 8
J. What other information will you get from us? ..................................................................... 8
Your WellCare Advocate Complete FIDA Participant ID card ............................................ 9
Provider and Pharmacy Directory ...................................................................................... 9
List of Covered Drugs ...................................................................................................... 10
The Explanation of Benefits ............................................................................................. 11
K. How can you keep your Participant record up to date? .................................................... 11
Do we keep your personal health information private? .................................................... 11

If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063
(TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call is free.
?
For more information, visit https://fida.wellcareny.com/. 3
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK Chapter 1:
Getting started as a Participant
A. Welcome to WellCare Advocate Complete FIDA
WellCare Advocate Complete FIDA is a Fully Integrated Duals Advantage (FIDA) Plan.
A FIDA Plan is an organization made up of doctors, hospitals, pharmacies, providers of
long-term services and supports, and other providers. It also has Care Managers and
Interdisciplinary Teams (IDTs) to help you manage all your providers and services. They
all work together to provide the care you need.
WellCare Advocate Complete FIDA was approved by New York State and the Centers
for Medicare & Medicaid Services (CMS) to provide you services as part of the FIDA
Demonstration.
FIDA is a demonstration program jointly run by New York State and the federal
government to provide better health care for people who have both Medicare and
Medicaid. Under this demonstration, the state and federal government want to test new
ways to improve how you receive your Medicare and Medicaid health care services. At
present, this demonstration is scheduled to last until December 31, 2017.
B. What are Medicare and Medicaid?
Medicare
Medicare is the federal health insurance program for:
 people 65 years of age or older,
 some people under age 65 with certain disabilities, and
 people with end-stage renal disease (kidney failure).
Medicaid
Medicaid is a program run by the federal government and New York State that helps
people with limited incomes and resources pay for long-term services and supports and
medical costs. It covers extra services and drugs not covered by Medicare.
Each state decides what counts as income and resources and who qualifies. Each state
also decides which services are covered and the cost for services. States can decide
how to run their programs, as long as they follow the federal rules.
Medicare and New York State must approve WellCare Advocate Complete FIDA each
year. You can get Medicare and Medicaid services through our plan as long as:
 You are eligible to participate in the FIDA Demonstration,
 We choose to offer the FIDA Plan, and
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-
2063 (TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call
?
is free. For more information, visit https://fida.wellcareny.com/. 4
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK Chapter 1:
Getting started as a Participant
 Medicare and New York State approve WellCare Advocate Complete FIDA to
participate in the FIDA Demonstration.
If at any time our plan stops operating, your eligibility for Medicare and Medicaid
services will not be affected.
C. What are the advantages of this FIDA Plan?
In the FIDA Demonstration, you will get all your covered Medicare and Medicaid
services from WellCare Advocate Complete FIDA, including long-term services and
supports (LTSS) and prescription drugs. You do not pay anything to join or receive
services from this plan. However, if you have Medicaid with a “spend-down” or “excess
income,” you will have to continue to pay your spend-down to the FIDA plan.
WellCare Advocate Complete FIDA will help make your Medicare and Medicaid benefits
work better together and work better for you. Here are some of the advantages of
having WellCare Advocate Complete FIDA:
 You will have an Interdisciplinary Team that you help put together. An
Interdisciplinary Team (IDT) is a group of people that will get to know your needs
and work with you to develop and carry out a Person-Centered Service Plan
specific to your needs. Your IDT may include a Care Manager, doctors, service
providers, or other health professionals who are there to help you get the care
you need.
 You will have a Care Manager. This is a person who works with you, with
WellCare Advocate Complete FIDA, and with your care providers to make sure
you get the care you need.
 You will be able to direct your own care with help from your IDT and your Care
Manager.
 The IDT and Care Manager will work with you to come up with a Person-
Centered Service Plan specifically designed to meet your needs. The IDT will be
in charge of coordinating the services you need. This means, for example:
» Your IDT will make sure your doctors know about all medicines you take so
they can reduce any side effects.
» Your IDT will make sure your test results are shared with all your doctors and
other providers.
» Your IDT will help you schedule and get to appointments with doctors and
other providers.

If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063
(TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call is free.
?
For more information, visit https://fida.wellcareny.com/. 5
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK Chapter 1:
Getting started as a Participant
D. What is WellCare Advocate Complete FIDA’s service area?
Our service area includes these counties in New York: Bronx, Kings, Nassau, New
York, Queens and Richmond.
Only people who live in our service area can join WellCare Advocate Complete FIDA.
If you move outside of our service area, you cannot stay in this plan.
E. What makes you eligible to be a plan Participant?
You are eligible for our plan as long as:
 you live in our service area;
 you are entitled to Medicare Part A, enrolled in Medicare Part B, and eligible for
Medicare Part D;
 you are eligible for Medicaid;
 you are age 21 or older at the time of enrollment;
 you require 120 or more days of community-based or facility-based LTSS or are
nursing facility clinically eligible and receive facility-based long-term support
services; and
 you are not excluded from enrollment based on one of the exclusions listed
below.
You will be excluded from joining our plan if:
 you are a resident of a New York State Office of Mental Health (OMH) facility or a
psychiatric facility;
 you are receiving services from the State Office for People with Developmental
Disabilities (OPWDD) system – whether receiving services in an OPWDD facility
or treatment center, receiving services through an OPWDD Waiver, whether you
could be receiving services in an ICF/IID but you have chosen not to, or
otherwise;
 you are expected to be Medicaid eligible for less than six months;
 you are eligible for Medicaid benefits only for tuberculosis related services,
breast cancer services, or cervical cancer services;
 you are receiving hospice services (at time of enrollment);
 you are eligible for the family planning expansion program;
 you are a resident of an alcohol/substance abuse long-term residential treatment
program;
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063
(TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call is free.
?
For more information, visit https://fida.wellcareny.com/. 6
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK Chapter 1:
Getting started as a Participant
 you are eligible for Emergency Medicaid;
 you are enrolled in the 1915(c) waiver program for Traumatic Brain Injury (TBI);
 you participate in and reside in an Assisted Living Program; or
 you are in the Foster Family Care Demonstration.
F. What to expect when you first join a FIDA plan
When you first join the plan, you will receive a comprehensive assessment of your
needs within the first 30 or 60 days depending on your enrollment type and date. The
assessment will be conducted by a Registered Nurse from WellCare Advocate
Complete FIDA.
If WellCare Advocate Complete FIDA is new for you, you can keep seeing the
doctors you go to now and getting your current services for a certain amount of time.
This is called the “transition period.” In most cases, the transition period will last for 90
days or until your Person-Centered Service Plan is finalized and implemented,
whichever is later.
After the transition period, you will need to see doctors and other providers in the
WellCare Advocate Complete FIDA network. A network provider is a provider who
works with WellCare Advocate Complete FIDA. See Chapter 3 for more information on
getting care.
There are two exceptions to the transition period described above:
 If you are a resident of a nursing facility, you can continue to live in that nursing
facility for the duration of the FIDA Demonstration, even if the nursing facility
does not participate in WellCare Advocate Complete FIDA’s network.
 If you are receiving services from a behavioral health provider at the time of your
enrollment, you may continue to get services from that provider until treatment is
complete, but not for more than two years. This is the case even if the provider
does not participate in WellCare Advocate Complete FIDA’s network.
G. What is a Person-Centered Service Plan?
After WellCare Advocate Complete FIDA’s Registered Nurse conducts the
comprehensive assessment, you will meet with the members of your Interdisciplinary
Team (IDT) to talk about your needs and develop your Person-Centered Service Plan
(PCSP). A PCSP is the plan for what health services, long-term services and supports,
and prescription drugs you will get and how you will get them.
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063
(TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call is free.
?
For more information, visit https://fida.wellcareny.com/. 7
WellCare Advocate Complete FIDA PARTICIPANT HANDBOOK Chapter 1:
Getting started as a Participant
You will have a comprehensive re-assessment when necessary, but at least every six
months. Within 30 days of the comprehensive re-assessment, your IDT will work with
you to update your PCSP. At any time, you may request a new assessment or an
update to your PCSP by calling your Care Manager.
H. Does WellCare Advocate Complete FIDA have a monthly plan
premium?
No. There is no monthly plan premium and there are no other costs for participating in
WellCare Advocate Complete FIDA. However, if you have Medicaid with a “spend-
down” or “excess income,” you will have to continue to pay your spend-down to the
FIDA plan.
I. About the Participant Handbook
This Participant Handbook is part of our contract with you. This means that we must
follow all of the rules in this document. If you think we have done something that goes
against these rules, you may be able to appeal, or challenge, our action. For information
about how to appeal, see Chapter 9, call 1-800-MEDICARE (1-800-633-4227), or call
the Independent Consumer Advocacy Network at 1-844-614-8800. You may also
complain about the quality of the services we provide by calling Participant Services at
1-855-595-2063 (TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday -
Sunday.
The contract is in effect for the months you are enrolled in WellCare Advocate Complete
FIDA between January 01, 2016 and December 31, 2016.
J. What other information will you get from us?
You should have already received a WellCare Advocate Complete FIDA Participant ID
card, a Provider and Pharmacy Directory, and a List of Covered Drugs.
If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063
(TTY/TDD 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday - Sunday. The call is free.
?
For more information, visit https://fida.wellcareny.com/. 8